Tuesday, July 29, 2014

Autism spectrum disorder
(ASD) and attention deficit hyperactivity disorder (ADHD) are
neurodevelopmental disorders with onset of symptoms in early childhood. There
is an overlap in the clinical presentation of ASD and ADHD with epidemiological
studies indicating an increase in prevalence rates of ASD and ADHD over the
past decade. Symptoms associated with both disorders often result in
significant behavioral, social, and adaptive problems across home, school, and
community settings Research suggests that when ADHD is comorbid with ASD, the
risk for increased severity of psychosocial problems increases. More severe externalizing, internalizing and social problems, as well as more impaired adaptive
functioning, have been
reported in children with comorbid ASD and ADHD than children identified with only
ASD.

Although there continues
to a debate about ADHD comorbidity in ASD, research, practice and theoretical
models suggest that comorbidity between these disorders is relevant and occurs
frequently. For example, studies conducted in the US and Europe indicate that
children with ASD in clinical settings present with comorbid symptoms of ADHD
with rates ranging between 37% and 85%. However, little is known, about comorbidity
rates in nonclinical (community) populations of children. Consequently, there
is a major need in the field of autism research to better understand how often
clinically significant ADHD symp­toms co-occur with ASD in nonclinical
populations, and whether the comorbidity of ADHD with ASD is related to
differences in other behavioral characteristics.

Current Research

A study published in the
journal Autism
examined rates of parent-reported clinically significant symptoms of ADHD in a
community sample of school-aged children (4-8 years) with ASD. The researchers
hypothesized that children with ASD and comorbid ADHD would exhibit a more
severe behavioral phenotype than those with only ASD. Specifically, they speculated
that the comorbid group would have lower cognitive functioning, greater delays
in adaptive func­tioning, higher rates of internalizing problems, and more
severe social impairment than children with only ASD when these groups were of
similar age. Participants included a sample of 153 children 4 to 8 years of
age, consisting of the following classification groupings: Non-ASD (n = 91),
ASD-Only (n = 44), and ASD+ADHD (n = 18). Children were evaluated on measures
of cognitive functioning, internalizing psychopathology, social functioning and
autism mannerisms, and adaptive behavior.

Results

Data analysis indicted
significant between-group differences. Results revealed that mean scores were
in the “healthy” range for the Non-ASD group, in the mild to moderately
impaired range for the ASD-Only group, and in the severely impaired range for
the ASD+ADHD group on measures of social functioning and adaptive functioning,
representing a continuum of impairment across groups. Children with ASD and
ADHD also had lower cognitive functioning than the ASD-Only group. There were
no group differences in parent ratings of symptoms of internalizing
psychopathology (mood and anxiety disorders), with none of the groups
demonstrating elevated rates of internalizing problems. The researchers suggest
that an explanation for this finding may be that symptoms of inattention or
hyperactiv­ity may obscure symptoms of anxiety in younger school-aged children.
In addition, internalizing problems may be difficult to distinguish in young
children with ASD as they may not be aware­ of their internal emotional states
and may have difficulty expressing their emotional condition to others due to
their ASD-related communication impairment.

Implications

The overall results of
this study indicate greater impairment in cognitive, social, and adaptive functioning for children with ASD and clinically significant ADHD symptoms in
comparison with children identified with only ASD. These findings suggest
that ADHD comorbidity may constitute a distinctive subtype of ASD and that
these children may be at higher risk of social impairment and adjustment
problems. The findings are also consistent with other research reports of more
severe social problems and maladaptive behav­iors in children with comorbid ASD
and ADHD than children with only ASD.

The findings of the study
have important implications for practitioners in health care, mental health,
and educational contexts. Overall, 29% of children with ASD also exhibited
clinically significant levels of ADHD. Although lower than rates in clinical
samples, the rate of comorbid ADHD indicates that young school-age children
with ASD should be assessed for ADHD. If clinically significant ADHD symptoms
are identified, and social development does not appear to be responding to
intervention, changes in the intervention pro­gram (e.g. intensity, strategies,
and goals) may be required. It is also important to note that a significant
change in the DSM-5 is removal of the DSM-IV-TR hierarchical rules prohibiting
the concurrent diagnosis of ASD and ADHD. When the criteria are met for both
disorders, both diagnoses are given. Thus, an assessment of ADHD characteristics
should be included whenever inattention and/or impulsivity are indicated as
presenting problems. It is imperative that practitioners recognize the high co-occurrence
rates of these two disorders as well as the potential increased risk for social
and adaptive impairment associated with comorbidity of ASD and ADHD. More
research is needed to further clarify the behavioral characteristics of
children with co-occurring ASD and ADHD so that specialized treatments and
interventions may be designed to improve outcomes and quality of life for this
subgroup of children. This is important because children who present with the
two disorders may have a higher risk for sub-optimal outcomes and may benefit
from different treatment methods or intensities than those with identified
with only ASD.

Wednesday, July 2, 2014

Aggression is a clinically
significant feature of many children and adolescents with autism spectrum
disorders (ASD). Children with ASD frequently have co-occurring (comorbid)
psychiatric conditions, with estimates as high as 70 to 84 percent. These
co-occurring problems often exacerbate the core symptoms of ASD and can lead to
significant functional impairment. Among these problems, physical aggression
appears to be especially challenging, and has been associated with serious
negative outcomes in both the general population and among individuals with ASD
and other developmental disabilities.

Co-occurring Problems
Relevant to Aggression

Children with ASD
experience a number of related difficulties, including sleep problems,
gastrointestinal (GI) problems, sensory abnormalities, and self-injury. Many of
these problems have been associated with aggression among typically developing
children, and emerging evidence suggests a similar relationship in children
with ASD. For example, sleep problems occur in a large percentage of children
with ASD, with prevalence rates ranging from 50% to 80%. Sleep problems have
been found to be highly associated with aggression in typically developing
children. Likewise, research suggests that children with ASD and sleep problems
are more likely to demonstrate aggression than those without sleep problems.

Sensory problems,
including sensory over-responsivity, sensory under-responsivity, and sensory
seeking are also common problems in children with ASD. In typical children,
sensory problems have been associated with aggressive and externalizing
behavior problems. Similarly, recent studies have been found correlations
between sensory problems and broadly defined externalizing problem behaviors in
children with ASD. However, research has yet to specifically examine the
potential contributing role of sensory problems in predicting physical
aggression.

Self-injurious behavior
also appears to be relevant to the occurrence of aggression. Individuals with
ASD are at an increased risk for demonstrating self-injurious behaviors, as
compared to those without ASD, with prevalence rates ranging from 30% to 53%.
Although self-injury and other forms of challenging behaviors have been
considered to be distinct forms of behavior, they are often related. For
example, physical aggression and self-injury have been significantly associated
among individuals with severe intellectual impairment and there is evidence
that self-injurious behaviors are precursors of later aggression in this
population. However, similar studies have not investigated the relationship
between self-injury and physical aggression in children with ASD.

Lastly, gastrointestinal
(GI) problems may also have relevance to the occurrence of aggression. GI
problems are common in children with ASD, with prevalence rates ranging from
24% to 70% or higher, depending on symptom definitions. Although there some
evidence of an association between behavior problems and GI problems in ASD, a
population-based study of children with ASD did not find significant
differences in aggression when comparing children with and without GI problems.

Current Research

Although the nature and
developmental course of aggression have been a focus of research with typically
developing populations, there have been few large-scale studies of group-level
predictors of aggression among individuals with ASD. Consequently, it is unclear
whether findings from the general population are applicable to children and
adolescents with ASD. In an effort to investigate the extent of the problem in
children and adolescents with ASD, a recent large-scale study published in Research in Autism Spectrum
Disorders examined the prevalence and correlates of physical aggression in
a sample of 1584 children and adolescents with ASD enrolled in the Autism
Treatment Network (ATN), a multi-site network of 17 autism centers across the
US and Canada. Participants in the study ranged in age from 2 to 17 years, with a mean age of 5.91 years. The
term “aggression” referred specifically to physical aggression and included
biting, hitting, or other physical aggression directed towards others. A number
of diagnostic, medical, and behavioral measures were collected at enrollment
and at regular follow-up intervals. Measures of interest included: (a)
aggression, (b) sleep disturbance, (c) sensory problems, (d) communication and
social functioning, (e) self-injury and gastrointestinal problems, (f) cognitive
functioning, and (g) verbal/nonverbal status. Data analyses were completed in
order to identify the variables most strongly associated with aggression.

Prevalence, Correlates and
Predictors of Aggression

The results indicated that
the prevalence of aggression was 53% across the entire sample of children, with
highest prevalence among young children. These results are highly consistent
with recently reported prevalence rates (56%) in another large-scale study of
children and adolescents with ASD. The results also indicate that age-related
decreases in aggression in children with ASD are similar to what has been
observed in typically developing children. It should be noted, however, that a large
percentage (nearly 50%) of the adolescents in the study’s sample continued to demonstrate
physical aggression. Thus, the relative decrease in aggression over time must
be balanced by the finding that these behaviors continued to occur at a high rate
among a large portion of adolescents with ASD.

In terms of predictors, the
results indicated that self-injury was highly associated with aggression among
children with ASD. This is consistent with the findings of other studies
showing a strong association between self-injury and other challenging
behaviors. The current results add to existing literature, and suggest that
children with ASD who demonstrate self-injury may be at risk for more severe
behavioral problems.

Sleep problems emerged as
a second significant predictor aggression. This association between sleep
problems and aggression is largely consistent with previous findings among both
typically developing children and those with ASD, indicating may underlie (and
exacerbate) aggressive behavior patterns for many children with ASD. It should
also be noted that sleep problems have been found to be associated with
self-injurious behaviors among individuals with intellectual disabilities and
that these two conditions may be related. In fact, there is some developing evidence
suggesting shared neurobiological basis for both sleep disturbance and
self-injurious behavior.

Sensory problems were also
significantly associated with aggression. These findings are consistent with
similar associations between sensory issues and aggression among typically developing
children. While previous research has demonstrated an association between
sensory problems and broadly defined behavior problems, the current results
extend these previous findings by demonstrating a specific relationship between
sensory problems and physical aggression.

Comparisons also indicated
that children with aggression were more likely to experience GI problems,
communication skill difficulties, and social skills difficulties. However,
these variables did not appear as significant predictors of aggression,
indicating that self-injury, sleep problems, and sensory issues accounted for
the majority of the variance in predicting aggression.

In terms of potential sex
differences, the results indicate that girls and boys with ASD were equally
likely to engage in aggression. This finding was unexpected in that research
has consistently shown a significant gender difference among children without
ASD, with boys being much more likely to engage in physical aggression than
girls. The results of the study suggest that the sex differential in aggression
may not be salient in the ASD population.

Implications

This study provides
evidence that aggression may be much more prevalent among children with ASD
than in the general population and that some co-occurring problems may place
individuals at risk for aggression. Aggression was significantly associated
with a number of clinical features, including self-injury, sleep problems,
sensory problems, GI problems, and communication and social functioning.
However, self-injury, sleep problems, and sensory problems were most strongly
associated with aggression. These findings indicate that co-occurring problems
specific to the ASD phenotype may play an important role in the occurrence of
aggression and that it is important to consider multiple domains of functioning
when assessing and treating aggression in children with ASD. For example, increased
attention should be given to the identification and treatment of sleep
problems, self-injury, and sensory problems. Given the significant relationship
between sleep problems and aggression, it is possible that treatments targeting
sleep problems may help reduce maladaptive behavior. Thus, assessment and
treatment of sleeping problems might be included as a standard and integrated
part of the assessment and treatment of ASD. Programs for children with ASD
should also integrate an appropriately structured physical and sensory milieu
in order to accommodate any unique sensory processing challenges. Although
assessment tools are limited, comorbid problems should be assessed whenever
significant behavioral issues (e.g., inattention, mood instability, anxiety,
sleep disturbance, aggression) become evident or when major changes in behavior
are reported. Coexisting disorders should also be carefully investigated when
severe or worsening symptoms are present that are not responding to traditional
methods of intervention.

Of course, more research
is needed in order to better understand the characteristics and course of
different types of aggression. For example, future research should examine the
longitudinal course of aggression, the role of these associated problems in
predicting improvement or worsening of aggression, and possible changes in
aggression in response to treatment for these co-occurring problems. Studies
are also needed to examine the role of additional family- and community-level
variables in the prediction and maintenance of aggression among children with
ASD.

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